Visual Acuity: check with eyes corrected (glasses or contacts). If unavailable, get notecard with 18g pin-hole in it (only parallel light rays to fall on macula and estimates corrected vision).

Snellen chart: 20 feet away and acuity is measured as 20/? with denominator is distance with a normal person could see those same letters. Determined by smallest line someone can read with one half of the letters correct. Rosenbaum chart can be used as near card (14 in from the patient).

Conjunctivitis: usually viral which is benign, self-limited. Bacterial: unilateral, though can be bilateral, mucopurulent discharge adherence of eyelids in the morning. Preauricular lymphadenopathy absent. Usually staph/strep. Need to do fluorescein staining to look for ulcer/abrasion/dendrite. Tx: topical abx 4x daily x 1 week. Polytrim fine, cipro/ofloxacin for contact wearers. Viral: adenovirus (pink eye): preceded by URI, watery discharge. Usually both eyes over the course of a few days. Preauricular adenopathy present. Look for follicles on inferior palpebral conjunctiva.

Herpes Zoster Ophthalmicus: shingles of first division of trigeminal nerve. Involves upper eyelid. Can involve tip of nose as well (Hutchinson sign). Cornea will have pseudodendrite where as HSV will have dendrite (stains better).

Endopththalmitis: inflammation of aqueous or vitreous humor that can lead to loss of vision. Most frequent cause is postsurgical followed by penetrating ocular trauma. Erythema and swelling of eyelids, sclera injection, chemosis, hypopyon, and uveitis. Tx emergent intravitreal abx and steroids + systemic abx.

Conjunctival Abrasion/Laceration: conjunctiva not innervated as much as cornea so not as painful. Rule out globe rupture with Seidel test (fluorescein should not flow out of laceration) though rupture can still occur if small or already closed.

Corneal Abrasion: highly innervated so can be extremely painful. Foreign body sensation, photophobia, tearing. Relief to pain with topical anesthesia is virtually diagnostic for abrasion. Iritis can occur if abrasion large or > 24 hours since injury. If there are several linear abrasions, consider looking for FB still stuck in the eyelid. Tx: cycloplegics (cyclopentolate 1% or homatropine 5% one drop q6-8hrs) relive some of the spasm and decrease secondary iritis. Topical NSAIDs like ketorolac and diclofenac give some relief and dont decrease healing time. Some recommend against giving topical anethetics to go home with.

Corneal Laceration: full thickness can have mishappen iris. Small lacerations though appear very similiar to abrasions and can close spontaneously and be Seidel test negative. Consider CT orbit with id globe anatomy, contour, FB. Sensitivity to detection occult globe perforation is 56-68%. Can convert to endophthalmitis or traumatic cataract.

Corneal FB: Metal sitting for several hours will form ‘rust rings’ – if longer than 24 hours, can get iritis. Presence of hyphema suggests globe perforation. Seidel test will be positive. Removal: Irrigate with NS first and see if very superficial FB will be irrigated off. Next, try moistened cotton applicator. Full thickness corneal FB should be removed by opthalmologist. Otherwise, 25g needle or sterile FB spud on Alger brush. Rust ring can be cleared by spur, but very often rust forms again the following day which can be toxic to the eye so will need to be seen by optho again the following day, but rust ring do not need to be removed in the ED. Tx: topical abx, cycloplegics, tetanus if needed, f/u with optho next day.

Lid Lacerations: Lacerations involving lid margins, within 6-8mm of medial canthus, involving lacrimal duct/sac, involving inner surface of lid, wounds associated with ptosis, those involving tarsal plate or levator palpebrae muscle (orbital fat present) need specialist repair. Can instill flourescein into eye and see if it appears in the wound to assess for canalicular involvement. Can sometimes be discharged if repair will occur the following day. Small lacerations <1mm at the lid edge do not need sutures and can heal spontaneously. Any laceration > 1mm at the lid edge needs repair by specialist.

Numb the lateral portion of the eyelid, your going to crimp it with hemostat to reduce capillary blood flow. Then cut (extend) the skin until you see the inferior ligament and cut that. That usually does it, but you can cut the superior ligament as well. Afterward, IOP decreases, APD resolves, visual acuity improves. Ophthalmologist really doesn’t do anything afterward. Doesn’t need to ‘re-attach’ the ligament or cosmetically fix the previous incisions. Usually heals well afterward.

Cyanoacrylate: superglue. Rarely permanent damage. Place large amounts of erythromycin ointment on the eye and it should clump together. Do not need to have all of it removed at once. Can have rest removed next day.

Flashing Lights/Floaters/Retinal Detachment: Always unilateral (bilateral usually means intracranial process such as opthalmic migraine). Vitreous gel shrinks over time causing it to separate from posterior wall. Average age of onset if 55yo. If gel separates successfully, floaters occur. If pull causes tear in retina, fluid can disperse into space and peel retina off called retinal detachement – dark veil or curtain in the field of vision. Most tears occur in peripheral retina. If tear involves macula, repair should occur within a few days. If not, should occur with 10 days. Ophtho consult for dilated indirect exam within 24 hours.

CNIII palsy: diabetic related usually with pupil spared. Unable to medial gaze, upward gaze and downward gaze as well as some ptosis. Lateral gaze will be preserved. diplopia worse with pt looking to contralateral side. If ipsalateral pupillary dilation noted, it is a posterior communicating artery aneurysm until proven otherwise.

30 degree test: check diameter with patient looking straight and then check it again with patient looking 30 degrees in another direction. If increased diameter due to increased ICP, the optic nerve stretches with the change in gaze and the diameter should be lower. If the diameter does not change, likely due to parenchymal infiltration or thickening of the optic nerve. (Emergency Ultrasound, Matthew Lyon and Michael Blaivas, 2008)

Q. Which eye drop for acute angle glaucoma is NOT used to decrease aqueous humor production? A. Pilocarpine – used to faciliate outflow. Timolol, apraclonidine, and acetazolamide are used to decrease production.